Clinical Geriatrics

Case Presentation

Mr. and Mrs. C are brought to the local hospital Emergency Department in an ambulance accompanied by the police. This older couple is well known to the Emergency Department staff due to their frequent visits for injuries. Mr. C is a 68-year-old retired construction worker who has been admitted several times to the hospital’s Chemical Dependency unit for alcohol withdrawal. Mrs. C is 64 years old and still works part-time as a bartender in a local pub. The couple has been married for 44 years and has three adult sons. Their youngest son, Mr. DC, frequently moves back home, as he has difficulty keeping a steady job, and sometimes works with his mother at the pub.

Mr. C is found to have alcohol on his breath and multiple lacerations on his face and hands. Mrs. C has a bruise over her left cheek and complains of pain over the area of her right ribs. When interviewed, the couple describes “getting into it again.” Mrs. C reports that she had returned home from her job at the pub at 3:00 am after waiting nearly one hour for her husband to pick her up. She had finally gotten a ride home from one of the patrons at the bar and became angry upon finding her husband sleeping on the couch surrounded by beer cans. She admits to screaming at him to wake him up. Mr. C reports that he had “had a few beers” to relax and woke up to a threatening, screaming wife who started hitting him with a glass vase. He admits to pushing her back and hitting her in the face. The police were called by Mr. DC, who heard them fighting. The police officers know the couple well. They make frequent visits to their home for complaints of domestic disturbances and sometimes are able to stop the confrontations before they become violent.

Mr. and Mrs. C have attended court-ordered anger management counseling and marital counseling after being issued citations by the police. They have returned to their pattern of episodic verbal and physical abuse after completing each program. The couple’s frequent visits to the Emergency Department of hospitals usually results in offers of counseling referrals, which they refuse. They often become remorseful and leave the hospital holding hands while promising to “treat each other better.” Usually their injuries are limited to superficial lacerations and bruises.

Mr. C is evaluated by the physician, who finds him to be tremulous, diaphoretic, and tachycardic. He complains of abdominal pain and vomits bright red blood. He is admitted to the Telemetry unit with a diagnosis of an acute gastrointestinal hemorrhage and alcohol withdrawal. Mrs. C is found to have three fractured ribs and a fracture of her left orbit. She frequently asks for pain medication by name and states that she prefers oxycodone. Mrs. C is admitted to the Surgery service for evaluation of her orbital fracture and need for surgery. Mrs. C is given morphine sulfate 8 mg subcutaneously every 3 hours for pain and lorazepam 2 mg intramuscularly every 4 hours for agitation. Several hours after admission, she demands more pain medication one hour after receiving morphine sulfate 8 mg and threatens to leave the hospital. She is given an additional dose of morphine sulfate 8 mg and is asked about her use of medications at home. She admits to taking multiple opioid medications daily, including up to 6 tablets of hydrocodone 5 mg with 6-8 tablets of oxycodone 5 mg. Mrs. C reports that she doesn’t drink alcohol but finds that pills help her “get through the day.” Her orbital swelling is prominent, and the surgeons are concerned that she may lose vision in her eye. A request is made for a social worker, caseworker from Adult Protective Services (APS), and psychiatrist to see both Mr. and Mrs. C.

Discussion

Domestic violence, often referred to as intimate partner violence, is not limited to young adults.